Analytical Validation of a Duplex Sequencing AML Assay with a Limit of Detection Below 0.01% VAF for SNVs and Indels

Sensitive, specific, precise, and accurate detection of low frequency mutations in acute myeloid leukemia (AML) is critical to assess measurable residual disease (MRD). Next generation sequencing (NGS) assays are powerful tools for this, permitting interrogation of thousands of base positions across genomic regions of interest. However, PCR and sequencing errors in these assays limit accurate mutation detection at variant allele frequencies (VAF) below approximately 1%. Duplex sequencing (DS), an error-corrected NGS (ecNGS) method, greatly reduces such errors by relating original top and bottom DNA strands to make double stranded consensus sequences, thus enabling sensitive, specific, accurate, and precise detection of variants below 0.01% VAF. Here, we report analytical validation of an updated DuplexSeq™ AML assay, a 36-gene panel informed by 2022 European LeukemiaNet (ELN) recommendations combined with kitted library preparation reagents and a cloud-based analysis pipeline. The assay uniformly targets regions that harbor AML-associated mutations: 82% of targeted regions exhibit sequencing depth >80% of the panel-wide mean and >99.5% of targeted regions exhibit depth >20% of the panel-wide mean. These analytical studies also validate an improved “v2 chemistry” version of a DS library preparation kit. This improved chemistry provides an enzymatic fragmentation step that replaces time-consuming mechanical fragmentation methods while increasing the yield of duplex data for a given input mass of DNA sample and eliminating damage that results from mechanical fragmentation. A contrived human genomic DNA sample carrying 26 variants targeted by the panel, DNA extracted from AML-positive peripheral blood (PB) and bone marrow aspirate (BMA) specimens, and DNA extracted from healthy normal PB specimens were used as test samples to execute limit of detection (LoD), limit of blank (LoB), accuracy, linearity, and repeatability & reproducibility studies. In this assay a duplex depth threshold of ≥20,000x is applied; ≥91.8% of the 42,605 genomic base positions targeted by the panel are consistently (in 95% of analyzed libraries) above this threshold. The LoD study assayed samples carrying variants from 0.37% to 0.00055% VAF. The assay demonstrated excellent sensitivity, with variants down to 0.00055% VAF detected. A probit model was used to estimate the VAF at which 95% of variants would be detected, establishing an LoD of 0.008% VAF for single-nucleotide variants (SNVs